Advances in psychosomatic medicine
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As opioid prescribing has dramatically expanded over the past decade, so too has the problem of prescription drug abuse. In response to these now two major public health problems - the problem of poorly treated chronic pain and the problem of opioid abuse - a new paradigm has arisen in pain management, namely risk stratification. Once a prescriber has determined that opioids will be used (a medical decision based on how intense the pain is, what has been tried and failed and, to some extent, what type of pain the patient has), he/she must then decide how opioid therapy is to be delivered. ⋯ Recently, researchers have produced a wide variety of literature regarding assessment tools to be used for this purpose. And while there remains a need for larger prospective studies to examine the ability of each tool to predict aberrant drug-taking behaviors, clinicians can and should utilize one or more of these screening tools and understand their benefits and limitations. This chapter will describe the nature of current screening assessments, their potential for use in the pain population in various settings, past clinical observations and suggestions for moving forward.
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Chronic opioid therapy for patients with chronic noncancer pain has become controversial, given the rising prevalence of opioid abuse. The prevailing literature suggests that the rate of addiction in chronic noncancer pain patients exposed to opioid therapy is relatively low, especially in those patients without significant concomitant psychiatric disorders and personal and family history of addiction. However, the escalating rate of misuse of prescription opioids has resulted in many clinicians caring for these patients to be more judicious in prescribing opioids. ⋯ Managing the patient with pain and co-occurring opioid abuse is equally challenging. Diagnostic issues, current guidelines for the appropriate use of opioids in the chronic pain population and risk stratification models are examined. Pharmacologic and nonpharmacologic treatment strategies for the patient with pain and opioid addiction are reviewed.
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Ketamine is an N-methyl-D-aspartate receptor antagonist that has been in clinical use in the USA for over 30 years. Its ability to provide profound analgesia and amnesia while maintaining spontaneous respiration makes it an ideal medication for procedure-related pain and trauma. In the chronic pain arena, its use continues to evolve. ⋯ Its potential ability to prevent 'windup' and, possibly, 'reboot' aberrant neurologic pathways in neuropathic and central pain states has generated intense interest. However, the long-term use of ketamine for chronic neuropathic pain is limited by its side effect profile, and is largely anecdotal. More research is needed to better ascertain its long-term efficacy and side effects, to determine the ideal candidates for sustained treatment and to develop means of exploiting the antinociceptive properties of ketamine while minimizing the adverse effects.
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Addictive drugs have in common that they are voluntarily self-administered by laboratory animals (usually avidly), and that they enhance the functioning of the reward circuitry of the brain (producing the 'high' that the drug user seeks). The core reward circuitry consists of an 'in-series' circuit linking the ventral tegmental area, nucleus accumbens and ventral pallidum via the medial forebrain bundle. Although originally believed to simply encode the set point of hedonic tone, these circuits are now believed to be functionally far more complex, also encoding attention, expectancy of reward, disconfirmation of reward expectancy, and incentive motivation. 'Hedonic dysregulation' within these circuits may lead to addiction. ⋯ Stress-triggered relapse involves (a) the central nucleus of the amygdala, the bed nucleus of the stria terminalis, and the neurotransmitter corticotrophin-releasing factor, and (b) the lateral tegmental noradrenergic nuclei of the brain stem and the neurotransmitter norepinephrine. Cue-triggered relapse involves the basolateral nucleus of the amygdala, the hippocampus and the neurotransmitter glutamate. Knowledge of the neuroanatomy, neurophysiology, neurochemistry and neuropharmacology of addictive drug action in the brain is currently producing a variety of strategies for pharmacotherapeutic treatment of drug addiction, some of which appear promising.
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Chronic pain and substance abuse are common problems. Each entity represents a significant and independent burden to the patients affected by them, the healthcare system caring for them, and society at large supporting them. If the two problems occur together, all of these burdens and their consequences are magnified. ⋯ Clearly, new approaches are required for the most complex of cases. Success is possible only if multiple disciplines provide integrated care that incorporates all of the principles of substance abuse and chronic pain rehabilitation treatment into one package. While experience provides the foundation for implementing these programs, research that documents the methods behind successful outcomes will be needed to sustain support for them.